BARRIERS TO ADEQUATE DELIVERY OF HEMODIALYSIS

Mortality rates among American hemodialysis patients are the highest i n the industrialized world. Measures of delivered dialysis (Kt/V) corr espond strongly with survival and are estimated to be inadequate in on e third of patients, We sought to determine the importance of potentia l barriers to adequate dialysis, including patient-related and technic al factors, Using a cross-sectional study design, we abstracted the ch arts of 721 randomly selected patients from all 22 chronic hemodialysi s units in northeast Ohio. For each of 1,836 treatments provided to th ese patients, we assessed delivered dialysis (Kt/V) and patient-relate d factors tie, hypotension, intradialytic symptoms, and treatment time missed due to noncompliance or transportation problems) and technical factors tie, dialysis prescription, type of vascular access, clotting , and dialyzer reuse), We used hierarchical regression analysis to det ermine which potential barriers were independently related to delivere d dialysis after adjustment for patient demographic and medical charac teristics. Barriers independently related to dialysis delivery (all P values <0.001) included patient noncompliance, present in 3% of treatm ents; low dialysis prescription, 14%; use of a catheter for vascular a ccess, 11%; and clotting, 1%, The prevalence of identified barriers va ried dramatically across facilities leg, the prevalence of low dialysi s prescription ranged from 0% to 37%, while the prevalence of catheter use ranged from 3% to 28%), In conclusion, patient noncompliance, low dialysis prescription, catheter use, and clotting are the most import ant barriers to dialysis delivery, Further work is needed to develop i nterventions to overcome these barriers and to determine the effect of such interventions on dialysis adequacy and patient survival. (C) 199 8 by the National Kidney Foundation, Inc.